Pain, dyspnoea and pilonidal sinus

Too busy to catch up on the latest research? Let Dr Lizzie Croton update you on recent papers.

Lumbar decompression and weight loss J Bone Joint Surg Am 2008; 90: 742-7
Overweight patients with neurogenic claudication secondary to spinal stenosis often find weight loss difficult due to their limited mobility. Many believe that decompression surgery will enable them to increase their activity levels and so lose weight.

This study examined patients who achieved pain relief through decompression and measured their post-operative weight change at a mean 34.4 months after surgery. The average age of patients in the study was 53 years. The majority of patients either maintained or increased their body weight by 2.4kg on average.

Relief of symptoms and increased functional ability did not seem to help patients lose weight. Obesity seems likely to be independent rather than simply a consequence of lumbar spinal stenosis.

Suicide and antidepressants J Epidemiol Community Health 2008; 62: 448-54
In developed countries, suicide rates have decreased in recent years. This is thought to be related to the use of antidepressants, in particular the SSRIs.

This Danish study used population-based record linkage to ascertain if this was indeed the case.

Patients were all over the age of 50 and living in Denmark between 1996 and 2000. Suicide rates were calculated together with antidepressant usage.

One in five older adults who committed suicide were receiving treatment at the time of death.

Patients receiving antidepressant therapy accounted for only 10 per cent of the observed decline in the suicide rate.

The authors concluded that more effective treatment may decrease the suicide rate further. It seems that the decline in suicide rates may be due mostly to factors other than antidepressants.

Breech delivery BMJ 2008; 336: 872-6

Risk of breech delivery is higher if either the father or mother of the baby were themselves breech at time of delivery. This Norwegian population-based cohort study examined birth records over a 37-year period.

They linked both fathers and mothers with their offspring and only included individuals where both parents and offspring were born as singletons.

As the researchers were specifically looking at breech delivery in the second generation, only the firstborn offspring of parents were included.

They found that men and women who were born as breech deliveries had more than twice the risk of breech delivery in their firstborn offspring when compared with parents born via cephalic delivery.

The strongest risk of recurrence was found in vaginally delivered offspring and there was no difference in offspring breech risk between deliveries where the mother had been breech as opposed to the father.

The increased risk of recurrence in breech delivery in offspring was present only for parents delivered at term.

Dyspnoea and heart failure Arch Intern Med 2008; 168: 741-8
Patients who are short of breath often present a clinical conundrum. The authors proposed that the use of N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing would improve diagnostic accuracy and reduce uncertainty.

Subjects in this study had presented to A&E with symptoms of dyspnoea. The managing doctors were asked to estimate the likelihood of acute cardiac failure. Clinical uncertainty was present in 31 per cent of patients, of which 56 per cent had acute cardiac failure.

Patients judged with clinical uncertainty had longer lengths of hospital stay and increased mortality and morbidity. This was especially so in patients with acute cardiac failure.

The use of NT-proBNP testing combined with clinical assessment appeared to reduce diagnostic uncertainty by increasing the likelihood of a diagnosis of cardiac failure in dyspnoeic patients.

This may cut down lengths of hospital stay and its associated disadvantages.

Healing after sinus surgery BMJ 2008; 336: 868-71
After pilonidal sinus removal patients can either have the wound closed primarily or packed and left to heal by secondary intention.

This meta-analysis and systematic review from Scotland looked at the effect of surgical technique on healing time, infection risk and sinus recurrence rate. Wounds primarily closed healed faster but with a higher sinus recurrence rate. There was no difference in infection rate between the two groups.

Surgical closure methods were also examined and midline closure was compared with off-midline closure. Wounds took longer to heal and were more likely to become infected and recur with midline closure when compared with off-midline closure.

Sick notes in GP consultations

Fam Pract 2008; 25: 20-6

Up to a third of GP consultations involve issuing a sick note. This qualitative study from Wales analysed patients' views of sickness certification.

Patients rarely attended 'just for a sick note'. They valued the opportunity to ask questions and seek advice. They also valued continuity of care, adequate consultation length and a holistic approach on the part of the GP to their illness.

Patients were not offended by the GP questioning them directly about returning to work.

It seems that GPs who simply issue sick notes to patients who ask for them may not be giving the patients what they really want.

- Dr Croton is a salaried GP in Birmingham and a member of our team who regularly review the journals.

The quick study

Lumbar decompression allowed spinal stenosis patients pain relief but the resulting increased functional ability did not help them lose weight.

Antidepressant use does not appear to be the main contributing factor in the decline in suicide rates.

Breech deliveries were more than twice as likely for a first born child if one of the parents of the child had themselves had a breech delivery.

Dyspnoeic patients may be more accurately diagnosed with NTproBNP testing.

Pilonidal sinus wounds after surgery tended to heal faster if primarily closed but recurred less if left to heal by secondary intention.

Illness-related issues should be discussed when issuing sick notes.

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